Pain pathways during labor:

Pain in labor arises from:

1. Contraction of the myometrium against the resistance of the cervix and perineum.
2. Progressive dilatation of the cervix and LUS.
3. Stretching and compression of pelvic and perineal structures.

Pain during 1st stage of labor:

- Viscreal pain from uterine contractions and cervical dilation.
- Confined to T10-12 during latent phase, T10-L1 during active phase.
- Visceral afferent fibers travel with sympathetic nerves uterine and cervical plexus
hypogastric and aortic plexuss enter the spinal cord with T10-L1 nerve roots.
- Pain initially in lower abdomen lumbosacral area, gluteal area, thighs, etc.
- Nulliparous and h/o dysmenorrhea greater pain.

Pain during 2nd stage of labor:

- Onset of perineal pain signals the beginning of second stage of labor.
- Stretching and compression of the pelvic and perineal structures intensifies the pain.
- Sensory innervation of the perineum by pudendal nerve (S2-S4) thus pain involves
the T10-S4 dermatomes.

Pain management during labor:

1. Psychological and Non-pharmacological techniques:
- Suppressed by reorganizing ones thoughts.
- Patient education and positive conditioning about the birthing process.
- Techniques like Lamaze (coaching parturient to take deep breath at the beginning of
each contraction f/b rapid, shallow breathing for the duration of contraction)
- Other techniques: hypnosis, TENS, biofeedback and acupuncture.
2. Parenteral agents:
- Concern of fetal depression limits the use of opioid analgesic and sedatives.
- Problem of using opioids to fetus: prolonged time to sustain respirations, respi
acidosis, loss of beat to beat variability in FHR, decreased fetal movements, etc.
- Other effects of opioids in mother: respiratory depression, maternal N & V, delay
gastric emptying.
- Doses of opioids (preferably using PCA:
o Meperidine: 10-25 mg IV or 25-50 mg IM. Maxm maternal and fetal
respiratory depression within 10-20 min following IV and 1-3 h following
IM thus administer when delivery not expected for up to 4 hr.
o Fentanyl: 25-100 mcg, has 3 to 10 min analgesic onset. Lower doses not
associated with respiratory depression.
o Morphine: not used
o Butorphanol: 1-2 mg, Nalbuphine: 10-20 mg: have no respiratory depression
but sedation with repeated doses.
o Ketorolac and NSAIDs not recommended because they suppress uterine
contractions and promote closure of ductus arteriosus.
o Ketamine: low doses 10-15 mg IV. Useful adjuvant to regional anesthesia or
just prior to delivery.
 o Inhaled nitrous oxide-oxygen has minimal effect on uterine blood flow or
uterine contractions.
3. Local anesthesia:
- Pudendal nerve block (using special needle Koback or guide Iowa trumpet): often
combined with perineal infiltrations of LA during 2nd stage of labor.
- Paracervical plexus blocks: not used because of high chance of fetal bradycardia,
uteroplacental insufficiency, increased levels of LA in fetal blood due to close
proximity of uterine artery.
4. Regional anesthesia:
- Epidural
- Spinal
- Combined Spinal Epidural
Drugs in regional:
- Opioids alone:
o In patients who cant tolerate functional sympathectomy eg. Hypovolemia,
significant CV diseases such as severe AS, TOF, Eisenmengers syndrome or
pulmonary HTN.
- Intrathecal opioids: in dose of 0.1 -0.5 mg onset is slow (45-60 min) and dose may
not be adequate in all.
- Others: fentanyl, meperidine.
- Hypotension following intrathecal opioids is due to resultant analgesia and
decreased circulating catecholamines levels.
- Epidural opioids:
- Morphine: relatively large dose required >7.5 mg and also it is only effective in 1st
stage of labor thus no recommended.

- LA/LA-opioid mixtures:
o Continuous lumbar epidural analgesia most versatile and commonly
employed technique analgesia for first as well as for subsequent vaginal
delivery/CS if necessary.
Walking epidural:
Very dilute LA mixtures in epidural (0.625%) generally do not produce motor blockade and
may allow some patients to ambulate.

Test dose in epidural:

Should be injected between contractions to help reduce the false positive signs of IV
injection (tachycardia due to painful contraction)

Drug given: after 5 min when signs of IV and intrathecal injection is absent total 10 ml of
0.0625%-0.125% of Bupivacaine or 0.1-0.2% of Ropivacaine combined with 50-100 mcg
Fentanyl (in 5 ml increments waiting 1-2 min between doses). OR alternatively, continuous
epidural infusion using 0.0625-0.1% Bupi and 1-5 mcg/ml Fentanyl at 10 mL/h
OR, a patient controlled epidural analgesia (PCEA).

F/b monitoring with frequent BP for 20-30 min or until the patient is stable.

Possible indications for GA during vaginal delivery

1. Fetal distress during the second stage.
2. Tetanic uterine contractions.
3. Breech extraction.
4. Version and extraction.
5. Manual removal of retained placenta.
6. Replacement of an inverted uterus.

Deaths due to GA are related to airway problems (inability to intubate, inability to ventilate,
or aspiration pneumonia).

Advantage of RA over GA in obstetrics:

1. Less neonatal exposure to potentially depressant drugs.*
2. Less chances of manipulation of airways and related complications.
3. Decreased risk of maternal pulmonary complications.
4. An awake mother at the birth of her child.
5. Option for using regional anesthesia for post op pain relief.
*regardless of the technique neonates delivered more than 3 min after uterine incision
have lower Apgar scores and pH values.

Advantages of GA over RA:

1. Very rapid and reliable onset.
2. Control over airway and ventilation.
3. Greater comfort the parturients who have morbid fears of needles and surgery.
4. Potentially less hypotension than RA.
5. Also is helpful in the event of severe hgic complications such as placenta accreta.

Signs of fetal distress:

1. Non reassuring FHR pattern.
a. Repetitive late deceleration.
b. Loss of fetal beat-to-beat variability associated with late or deep
deceleration.
c. Sustained fetal heart rate <80/min.
2. Fetal scalp pH <7.20
3. Meconium stained amniotic fluid.
4. IUGR

Predisposing factors for umbilical cord prolapse:

1. Excessive cord length.
2. Malpresentation
3. Low birth weight.
 4. Grand parity (more than five pregnancies)
5. Multiple gestations
6. Artificial rupture of membranes.

Diagnosis suspected: after sudden fetal bradycardia or profound decelerations.

Treatment:
- Immediate steep Trendelenburg or keen chest position
- Manual pushing of the presenting fetal part back up into the pelvis until immediate
CS under GA can be performed.
- If the fetus is not viable, vaginal delivery is allowed to continue.

Dystocia and Abnormal Fetal Presentations and Positions:

Prolonged latent phase: Latent phase exceeding 20 h in a nulliparous parturient and 14 h in
a multipara. The cervix usually remains at 4 cm or less but is completely effaced.

Arrest of dilation: when the cervix undergoes no further change after 2 h in the active phase
of labor.

Protracted active phase: slower than normal cervical dilation defined as less than 1.2 cm/h
in a nulliparous and less than 1.5 cm/h in multiparous.

Prolonged deceleration phase: when cervical dilation slows markedly after 8 cm. The cervix
becomes very edematous and appears to lose effacement.

Prolonged 2nd phase (disorder of descent): as a descent of less than 1 cm/h and 2 cm/h in
nulliparous and multiparous respectively.

Arrest of descent: Failure of the head to descend 1 cm in station after adequate pushing.

Drug of choice:
Oxytocin is DOC in the treatment of uterine contractile abnormalities.
Administration: IV at 1-6 mU/min and increased in increments of 1-6 mU/min every 15-40
min depending on the protocol.
Use of amniotomy is controversial.
Management is expectant: as long as the fetus and mother are tolerating the prolonged
labor.
When trial of oxytocin is unsuccessful or when malpresentation or CPD is also present,
operative vaginal or CS delivery is indicated.

Breech presentation
- Occur in 3-4% of deliveries.
- Increase neonatal mortality and incidence of cord prolapse >10X.
Management:
- ECV may be attempted after 34 weeks of gestation and prior to the onset of labor
(obstetrician may administer tocolytic agent at the same time)
 o Role: ECV can be facilitated and its success rate improved by providing
epidural analgesia with 2% lidocaine and fentanyl.
o When unsuccessful: it can also cause placental abruption and umbilical cord
compression necessitating immediate CS.
o Role of epidural in Breech:
Need for breech extraction doesnt appear to be increased when
epidural is used for labor if labor is established prior to activation of
epidural.
Epidural anesthesia may decrease the likelihood of trapped head
because of relaxation of the perineum.
o If at all, head gets trapped even during regional, urgent RSI and GA to relax
uterus OR alternatively, Nitroglycerin 50-100 mcg IV may be administered.

Obstetric Hge:
1. Placenta Previa:
- Occurs if the placenta implants in advance of the fetal presenting part.
- 0.5% of pregnancies.
- Increase risk in females with:
o Previous CS or uterine myomectomy
o Multiparity
o Advanced maternal age
o Larger placenta
- Anterior lying placenta previa increases the risk of excessive bleeding for CS.
C/F:
o usually presents as painless vaginal bleeding.
o Often severe hge can occur at any time.
Management:
- When gestation <37 weeks and bleeding is mild to moderate: treated with bed rest
and observation.
- When >37 weeks: delivery by CS.
- Patient with low-lying placenta may rarely be allowed to deliver vaginally if bleeding
is mild.
- Active bleeding or unstable patients: require immediate CS under GA.
Preparation:
- Two large-bore IV catheters inplace
- Replacement of IV volume deficits.
- Blood must be available for transfusion.

2. Abruptio Placenta:
- Premature separation of normal placenta complicates approximately 1-2% of
pregnancies.
- Mild (grade I), moderate (II), severe (grade III)- 25%.
- Risk factors:
o HTN
o Trauma
o Short umbilical cord
o Multiparity
 o Prolonged premature rupture of membrane
o Alcohol abuse
o Cocaine use
o Abnormal uterus
C/F:
- Painful vaginal bleeding
- Uterine contraction and tenderness
- An abdominal USG can help in the diagnosis
Choice of anesthetics:
- Based on urgency for delivery, maternal hemodynamic stability and any
coagulopathy (severe abruption may cause coagulopathy particularly after fetal
demise- fibrinogen levels <150 mg/dL d/t activation of circulating plasminogen
(fibrinogen) and the release of tissue thromboplastins that precipitate DIC; platelet
counts low and factors V and VIII are low, Fibrin split products increased.).
- Bleeding may remain concealed inside the uterus and cause underestimation of
blood loss.
Management:
- Life threatening condition
- Emergency CS
- Massive blood transfusion
- Replacement of coagulation factors and platelets.

3. Uterine rupture
- Relatively uncommon.
- Occurs d/t:
o Dehiscence of scar from previous CS, extensive myomectomy or uterine
reconstruction.
o Intrauterine manipulations or use of forceps (iatrogenic)
o Spontaneous rupture following prolonged labor in patients with hypertonic
contractions (oxytocin use), fetopelvic disproportion, or very large thin and
weakened uterus.
C/F:
- Frank Hge
- Fetal distress
- Loss of uterine tone
- Hypotension
- Occult bleeding into the abdomen
- Abrupt onset of continuous abdominal pain and hypotension.
T/t:
- Volume resuscitation
- Immediate laparotomy typically under GA
- Ligation of internal iliac arteries (hypogastric) with or without hysterectomy.

PROM and Chorioamnionitis

- PROM is present when leakage of amniotic fluid occurs before the onse of labor.
- Diagnosis: The pH of amniotic fluid changes Nitrazine paper from BLUE to YELLOW.
- Complicates 10% of all and 35% of premature deliveries.
 - Predisposing factors:
o Short cervix
o Prior h/o PROM or preterm delivery
o Infection
o Multiple gestation
o Polyhydramnios
o Smoking
- Spontaneous labor commences in 90% of patients within 24 hrs of PROM.
- Issues in PROM: Risk of prematurity versus risk of infection.
- Longer the interval between PROM and onset of labor higher the incidence of
chorioamnionitis.
- PROM also predisposes to placental abruption and post partum endometritis.
Management:
- Gestation <34 weeks: Expectant management with prophylactic antibiotics and
tocolytics for 5-7 days.

Chorioamnionitis:
- Principal maternal complications are:
o Premature or dysfunctional labor
o Intra-abdominal infection
o Septicemia
o PPH
- Fetal complications:
o Acidosis
o Hypoxia
o Septicemia
C/F:
- Fever (>38 deg C)
- Maternal and fetal tachycardia
- Uterine tenderness
- Foul smelling or purulent amniotic fluid
Lab: TLC (only if markedly elevated >15000/micL), CRP (>2 mg/dl), Gram staining of amniotic
fluid

Considerations:
- Use of regional anesthesia in chorioamnionitis is controversial (chance of
development of meningitis or epidural abscess)
- Concerns over hemodynamic stability: particularly in patients with chills, high fever,
tachypnea and changes and mental status or borderline hypotension.
- May have covert signs of septicemia, thrombocytopenia, or coagulopathy.

Issues in Preterm Delivery:

- PROM and Preterm predispose to umbilical cord compression fetal hypoxemia and
asphyxia
- Preterm with breech: prone to prolapse of umbilical cord during labor
- Inadequate surfactant production: HMD after delivery
- Soft, poorly calcified cranium predisposes to intracranial Hge during vaginal delivery
 Management: Based on gestational age, fetal maturity.

a. Preterm labor before 35 WOG:

Bed rest and tocolytic therapy initiated.
Labor is inhibited until the lungs are mature and sufficient
pulmonary surfactant is produced.
When amniotic fluid L/S ratio is >2, the risk of prematurity is
reduced.
Glucocorticoid may be given to induce production of pulmonary
surfactant which req minimum of 24-48 hours.
Most commonly used tocolytic therapies are:
1. Beta adrenergic agonists: Ritodrine (IV 100-350 mcg/min or
Terbutaline (oral 2.5 5 mg every 4-6 hr); maternal S/E:
tachycardia, arrhythmia, MI, hyperglycemia, and rarely
pulmonary edema.
2. Magnesium (6 g IV over 30 min f/b 2-4 g/hr)
3. Others: calcium channel blockers (Nifedipine), PG synthetase
inhibitors, oxytocin antagonist (Atosiban), and Nitric oxide.
When tocolysis fails to arrest labor, anesthesia becomes necessary.

(Role: know that above mentioned drugs are given, eg. Magnesium
given (interaction with NMBD, vasodilation), its role, beta
adrenergic agonists are given thus their interaction, fetal is
premature thus need to resuscitate may be- eg. Ketamine/ephedrine
should be used cautiously).

Hypertensive Disorders:
HTN during pregnancy can be classified as:
o Pregnancy induced HTN: also referred to as preeclampsia
o Chronic HTN: that preceded pregnancy
o Chronic HTN with superimposed preeclampsia
- Preeclampsia:
o Is defined as SBP >140 mm Hg or DBP >90 mm Hg after the 20 th WOG
accompanied by proteinuria (>300 mg/d) and resolving within 48 h after
delivery.
o Complicates about 7-10% pregnancies.
o Severe preeclampsia causes 20-40% of maternal deaths and 20% of perinatal
deaths.
o Maternal deaths are usually d/t stroke, pulmonary edema, hepatic necrosis
or rupture.
o Severe features: BP >160/110 mm Hg, Proteinuria >5g/d, Oligura <500
ml/day, elevated serum creatinine, IUGR, pulmonary edema, CNS
manifestations (headache, visual disturbances, seizures, stroke), hepatic
tenderness, or HELLP syndrome.
- Eclampsia:
o Preeclampsia + Seizure
- Pathophysiology and Manifestations:
 o Vascular dysfunction of the placenta resulting in abnormal metabolism of
prostaglandin.
o In preeclampsia: Elevated TXA2 and decreased PGI2
TXA2 is a potent vasoconstrictor and promoter of platelet
aggregation, PGI2 is a potent vasodilator and inhibitor of platelet
aggregation.
o Endothelial dysfunction may reduce production of NO and increase
production off ET-1 (a potent vasoconstrictor and platelet aggregator)
o Marked vascular reactivity and endothelial injury reduce placental perfusion
and lead to widespread systemic manifestations.

- T/T:
o Bed rest
o Sedation
o Repeated administration of antihypertensives
Labetalol: 5-10 mg IV
Hydralazine: 5 mg IV
Magnesium sulphate